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Integrated Care

Overview

Integrated Care combines primary health care and mental health care in one setting. There are many ways to integrate care, and they may go by different names, including “Collaborative Care” or "Health Homes." This is an important model of care because:

Primary care settings, like a doctor's office, provide about half of all mental health care for common psychiatric disorders

Adults with serious mental illnesses and substance use disorders also have higher rates of chronic physical illnesses and die earlier than the general population

People with common physical health conditions also have higher rates of mental health issues.

Providing Integrated Care helps patients and their providers. It blends the expertise of mental health, substance use, and primary care clinicians, with feedback from patients and their caregivers. This creates a team-based approach where mental health care and general medical care are offered in the same setting. Coordinating primary care and mental health care in this way can help address the physical health problems of people with serious mental illnesses.

Why Is It Important?

Addressing the whole person and his or her physical and behavioral health is essential for positive health outcomes and cost-effective care. Many people may not have access to mental health care or may prefer to visit their primary health care provider. Although most primary care providers can treat mental disorders, particularly through medication, that may not be enough for some patients. Historically, it has been difficult for a primary care provider to offer effective, high-quality mental health care when working alone. Combining mental health services/expertise with primary care can reduce costs, increase the quality of care, and, ultimately, save lives.

Addressing Physical and Behavioral Health

Untreated or undertreated mental illnesses have serious consequences. People with severe mental illness often die 13-30 years earlier than the general population from medical conditions that could have been treated by a primary care provider.

Treating Children

Most children with mental health conditions are treated in a primary care setting instead of a specialized mental health setting. About half of all mental health disorders begin by age 14. Accurate diagnoses and quality care are vital in a primary care setting.

Treating Adults

Adults are also more likely to be seen in a primary care setting than within a mental health system. Primary care providers deliver half of the mental health care for common conditions such as anxiety, ADHD, depression, behavioral problems, and substance use. Yet, people with mental illnesses who are treated in a primary care setting are less likely to receive effective behavioral health care. For example, 75 percent of adult patients with depression see primary care providers, but only half are accurately diagnosed. When a referral is made to a mental health provider, only about half of patients follow through with making an appointment. As a result, many behavioral health problems go undetected, undertreated, and/or untreated.

How Does It Work?

Integrated Care meets all of a patient’s health needs in one setting. It can be delivered in multiple ways depending on who is providing the care, what type of care is being provided, where the care is taking place, and how services are being coordinated. Integration can take place in behavioral health, primary care, specialty clinics, and home health settings.

Within each category, there are varying degrees of collaboration between care providers. These levels range from minimal to full integration. Minimal integration is when medical and mental health care providers work in separate facilities, have separate systems, and rarely communicate. Full integration involves a single health system’s medical and mental health care providers working simultaneously to treat a patient’s behavioral and medical needs with shared medical record access.

The following are examples of Integrated Care programs:

Collaborative Care

A team-based Collaborative Care program adds two new types of services to usual primary care: behavioral health care management and consultations with a mental health specialist.

The behavioral health care manager becomes part of the patient’s treatment team and helps the primary care provider evaluate the patient’s mental health. If the patient receives a diagnosis of a mental health disorder, and wants treatment, the care manager, primary care provider, and patient work together to develop a treatment plan. This plan may include medication, psychotherapy, or other appropriate options.

Later, the care manager reaches out to see if the patient likes the plan, is following the plan, and if the plan is working or if changes are needed. The care manager and the primary care provider also regularly review the patient’s status and care plan with a mental health specialist, like a psychiatrist or psychiatric nurse, to be sure the patient is getting the best treatment options and improving.

Patient-Centered Medical Home (PCMH)

Another Integrated Care model is the patient-centered medical home (PCMH). PCMH involves coordinating a patient’s overall health care needs at any age. Patients play active roles in their health care. Providers coordinate all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology.

As a result of the Affordable Care Act, health homes were established for individuals on Medicaid with chronic conditions including mental health and substance use disorders, asthma, diabetes, heart disease, and obesity. Health homes are team-based with a whole-person approach with specific emphasis on integrating behavioral health and primary care. Health homes provide comprehensive care management, coordination, and follow-up. They also offer patient and family support, referrals to community and support services, and health promotion.

Hub-Based Systems

Found mostly in the child mental health world, hub-based systems modeled on the Massachusetts Child Psychiatry Access Project (MCPAP) provide primary care providers with immediate telephone consultations with a child psychiatrist. Case management and face-to-face evaluations are also available for complicated cases.

Four Quadrant Model

The Four Quadrant Model is a way to measure an organization’s level of integration.

The Four Quadrant Clinical Integration Model describes integration levels in terms of primary care and behavioral health care complexity and risk. The location, types of providers, and services vary depending on the complexity of patients’ conditions.

For instance, individuals with mild-to-moderate physical and/or behavioral health issues may be best cared for in a primary care setting with integrated behavioral health providers. For patients with complex general medical conditions as well as mild-to-moderate behavioral health disorders, a medical specialty setting with integrated behavioral health providers may be appropriate. Those with severe behavioral problems as well as medical conditions may receive the most comprehensive care in a specialty behavioral health center with integrated general medical providers, or a health home.

Pediatric versus Adult Integrated Care

Pediatric Integrated Care differs from adult Integrated Care in three main ways:

There is an increased sensitivity to how children are developing, both mentally and emotionally

The general principles of Integrated Care apply to adults as well as children and adolescents, but work with developing youth and their families is often different from the work with adults with complex medical illness. In addition, ongoing evaluation for intellectual disability and developmental delays will be emphasized in pediatric evaluations.